Valued Voice

On Jan. 26, WHA expressed support for a proposed federal rule change that would make it easier for Medicare Advantage enrollees to switch to another health plan or traditional Medicare when they are affected by a mid-year provider network change.

In its proposed rule to revise Medicare Advantage program regulations for contract year 2027, the Centers for Medicare & Medicaid Services (CMS) proposes changing the existing criteria that make a Medicare Advantage enrollee eligible for a special enrollment period when one or more of their providers leave the plan’s network. 

“Given increasing volatility in the (Medicare Advantage) market in Wisconsin and nationwide, WHA supports CMS’ efforts to make it easier for enrollees to change plans or disenroll to traditional Medicare when they are affected by mid-year provider network disruptions,” wrote WHA President and CEO Kyle O’Brien in the association’s comment letter to CMS.

Currently, when a Medicare Advantage health plan decides to terminate its contract mid-year with a hospital or health system, for example, the health plan and CMS must work through a multi-step process of determining and notifying an enrollee of their eligibility to switch plans outside the standard annual Medicare Open Enrollment Period. This process delays notification to impacted Medicare Advantage enrollees of their rights and options to change plans.  

Under the current process, the Medicare Advantage plan and CMS must determine whether the plan’s network change was significant enough to want a special enrollment period for affected enrollees. 

In the change proposed by CMS, a Medicare Advantage plan or CMS would no longer need to determine if a provider network change was significant enough to trigger a special enrollment period for provider network changes. Instead, CMS proposes to give Medicare Advantage enrollees the option to switch plans or disenroll to traditional Medicare whenever they are affected by a provider network change. 

In WHA’s comments to CMS, O’Brien noted the Medicare Advantage market in Wisconsin has been growing increasingly turbulent for the state’s hospitals and health systems due to the actions of some Medicare Advantage organizations. 

“Hospitals located across Wisconsin, for example, have been receiving unexpected notices from some (Medicare Advantage) plans, saying that their respective hospitals will no longer be in-network and cutting off access to care for (Medicare Advantage) enrollees in that plan,” wrote O’Brien. “Likewise, some hospitals have decided to terminate their contracts with (Medicare Advantage) plans due to the increasing burden of excessive prior authorization, inappropriate denials, downgrades and other hurdles some plans have thrown up that can result in delayed or denied patient care and ultimately drive up the overall cost of health care.”   

In WHA’s comment letter, O’Brien also recommended two additional changes that would help prevent care interruptions when Medicare Advantage enrollees are affected by a change in their plan’s provider network. WHA recommended:

• CMS expand the definition of an “affected enrollee” to include an enrollee who is scheduled to receive care from a provider or facility at the time they receive a provider termination notice. Expanding the definition in this way would capture instances, for example, where a patient has been referred to a new provider for time-sensitive care such as surgery, post-discharge follow-up, or specialty care. 
• CMS clarify that the special enrollment period for provider terminations would also be triggered when a hospital, health system or other provider decides to leave a Medicare Advantage plan’s network. The qualifying criteria in the current rule suggests this special enrollment period is only available when the Medicare Advantage plan initiates the provider network change.

Contact WHA Vice President, Medicaid & Payer Reimbursement Policy Christian Moran with questions.